SICLC Hardship Fund form

Snohomish & Island County Labor Council

Hardship Fund CONFIDENTIAL Assistance Form

Please Note: You must be a Union member to be eligible for assistance.

* Indicates required entry

Name

First NameLast Name

Best Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email Address

example@example.com

Union Houshold?

Number of People in Household:

Union Name & Local:

Union Contact & Phone:

Please Check Where Assistance is Needed and Amount Requested:

Select All That Apply:

Other Details:

Rent Amount:

Utilities Amount:

Food Amount:

Other Amount:

Please be very explicit with your explanation for your hardship and prioritize your greatest needs.

Signature

Date

FOR OFFICIAL USE ONLY

Notes